CSH Membership and Renewal Application

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A. Member Information   * Membership Status: New   Renewal * Membership Type: Regular Retired Student (requires proof of status )* * Chapter: Select a Local Chapter Los Angeles/San Bernardino Northern San Diego San Joaquin

B. Contact Information   * Full Name: * Email: Secondary Email:     * Home Address: * City: * State: * Zip Code:     Employer: Employment Address: City: State: Zip:     Preferred Mailing Address: Home   Work     * Phone (Home): xxx-xxx-xxxx Phone (Work): xxx-xxx-xxxx ext. xxxx

C. Student Information (for students members only) * School Affiliation: * Contact Information for Program Director:

D. Background (check all applicable boxes)   Certificate Degree Work Experience   HT (ASCP) AA/AS Hospital   HTL (ASCP) BA/BS Clinical   MT (ASCP) MA/MS Private Lab   CT (ASCP) PhD University   Other MD/DVM Industry       Veterinary       Sales       Education       Student

E. Automated submission check   This test prevents automated submissions Enter the text that appears in above image:

* Student Category requires Proof of Status
Student must be enrolled in an NAACLS accredited laboratory science
program (i.e. histology, cytology, clinical laboratory science, phlebotomy)